Achieving Whole Health A New Approach for Veterans and the Nation (2023) / Chapter Skim
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3 Evidence Supporting Whole Health's Foundational Elements
3 Evidence Supporting Whole Health's Foundational Elements
Pages 59-114
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From page 59... ...
The committee also defined whole health care as "an interprofessional, team-based approach anchored in trusted longitudinal relationships to promote resilience, prevent disease, and restore health. It aligns with a person's life mission, aspiration, and purpose." The committee further identified five foundational elements of a whole health approach, which includes being (1)
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From page 60... ...
and Medicine (National Academies) report Implementing High-Quality Primary Care noted that primary care is the only part of the health care system in which an increased presence is associated with longer lifespans and improved health equity, attributes often associated with well-being (NASEM, 2021)
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From page 61... ...
In this chapter the committee reviews the evidence supporting the foundational elements of a whole health approach. To identify the evidence supporting each of the five elements, the chapter focuses on each separately, but the committee recognizes that all elements are interdependent and that there is significant overlap across the elements.
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From page 62... ...
. Three others highlight the importance of coordinated and integrated care when it is necessary to engage the expertise of multiple professionals in a person's care.
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Sixteen studies were identified from two systematic reviews (McMillan et al., 2013; Smith et al., 2021) , and two papers published after these reviews were further identified for inclusion (Fortin et al., 2022; Stewart et al., 2021)
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From page 64... ...
64 ACHIEVING WHOLE HEALTH TABLE 3-1 Complementarity of the People-Centered Clinical Method and the VA Whole Health System People-Centered Clinical Method VA Whole Health System Person at the Center "Me" at the Center Person's Experience Exploring health, disease, and the illness You are expert on your life Experience by following cues to - Aware of your thoughts and feelings - Symptoms, signs, laboratory and other results - Meaning of health to the patient and aspirations for life - Patient's illness experience including feelings, ideas, function, and expectations Person in Context Understanding the whole person in Surroundings -- home, work, neighborhood, context climate, and environment - Patient as a person - Experiences that affect emotions - An individual developmental - Personal development -- ways you can trajectory and personality grow - Spiritual dimensions - Family, friends, coworkers can affect - A family, social support, and work emotions, mental and physical health - Community and culture - Reduce stress through relationships - Spirituality -- what gives meaning to life Discussion of Goals and Preferences Finding common ground Your values, goals and priorities - Mutual discussion between the - Set your health and well-being goals patient and clinician on the nature - Moving the body of the problems, goals, and roles - Food and drink of each - Recharge - Reaching mutual agreement - Power of the mind -- mind–body approaches Relationship Enhancing the Patient–Clinician Reduce stress through relationships (including Relationship patient–clinician relationship) - Surfacing emotion - Relationships can affect emotional health - Compassion, caring, empathy, and - Be aware of thoughts and feelings trust - Power in the relationship - Continuity of the relationship and constancy - Engendering healing and hope - Clinician self-awareness - Transference and counter transference
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From page 65... ...
Collectively, these findings demonstrate a mechanism whereby patient-centered interventions affect outcomes. First, patients notice that care delivery is better (more patient-centered)
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From page 66... ...
A meta-analysis of 33 randomized controlled trials of interventions designed to increase "meaning in life" among people who had experienced adversity or disease reported moderate evidence for improved measures related to meaning in life or purpose in these populations. This review also noted that some of the interventions were relatively brief and did not require licensed professional leaders (Manco and Hamby, 2021)
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From page 67... ...
Comprehensive describes what care is being provided, and holistic describes how care is provided. Comprehensive care means that care addresses all domains of conventional medical care as well as addressing upstream factors influencing health (see below)
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Evidence from multiple studies shows that team-based chronic care improves outcomes for multiple chronic conditions (Coleman et al., 2009)
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, each with ample evidence to demonstrate that their delivery results in improved length and quality of life, Americans receive only about half of recommended preventive care services (McGlynn et al., 2003)
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. Oral, Vision, and Hearing Care The importance of addressing oral health in a whole health approach is supported by a growing body of evidence linking oral health, particularly periodontal disease, to an increased risk and progression of chronic diseases, including diabetes, heart disease, and stroke, as well as low birth weight and premature birth in pregnant women (Bensley et al., 2011; Elani et al., 2018)
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. The protective effect in the studies with initially health populations was independent of social support, negative mood, socioeconomic status, and health behaviors such as alcohol consumption, exercise, and smoking.
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and (2) the model of integrated behavioral health in primary care (Cubillos et al., 2021; Hunter et al., 2018)
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Primary Care Behavioral Health Model Evidence also supports the seamless integration of behavioral health into primary care as important to whole health. Primary care behavioral health (PCBH)
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. Another study in a rural setting found that over 90 percent of individuals initially referred for behavioral health care via a warm handoff had a subsequent behavioral health visit, compared with 50 percent of 3 A warm handoff is a transfer of care between two members of a health care team while the individual receiving care (and their family if applicable)
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From page 75... ...
With multisector and community partnerships, health systems can address these upstream factors and improve health and well-being, making this capacity foundational for whole health systems. Health Behaviors A whole health approach should address unhealthy behaviors, which are a demonstrably significant contributor to poor health.
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From page 76... ...
However, a major challenge is that changing these foundational elements of peoples' lives requires intensive support over a prolonged period from a multidisciplinary team, often taking 30 or more hours over 6 or more months. Ample evidence has also shown that community-based interventions improve diet and physical activity for people (Khan et al., 2009)
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From page 77... ...
. Social Needs Social needs -- defined here as housing, food, transportation, finances, employment, education, and safety -- constitute a key upstream factor that contributes to poor health and therefore must be addressed in any whole health approach.
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. To address social needs, the National Academies, the World Health Organization, and many others have called for integrating conventional medical care and social care (IOM, 2016; Landon et al., 2012; Marmot et al., 2008)
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(4) Design and implement integrated care systems using ap proaches that engage patients, community partners, frontline staff, social care workers, and clinicians in the planning and evaluation and incorporating the preferences of patients and communities.
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A recent systematic review showed that allostatic load was associated with racial and ethnic discrimination and poor health outcomes (Guidi et al., 2021)
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From page 81... ...
. The VA has implemented additional services to more comprehensively provide women's health care, but the American College of Obstetricians and Gynecologists has noted the need for improved integration of these services into the VA health care infrastructure, which must include access to preventive health care services such as reliable, effective contraception (McCauley and Ramos, 2020)
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From page 82... ...
. LGBTQ+ veterans have even higher levels of PTSD than heterosexual and cisgender veterans yet a study of women LGBTQ+ veterans found that compared to heterosexual and cisgender women, they face additional barriers to care, such as experiencing more harassment and feeling unwelcome or unsafe when seeking care at VA facilities.
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From page 83... ...
Studies have linked outdoor pollution in the form of ozone and fine particles (PM2.5) to ischemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, lower respiratory infection, and lung cancer (Cohen et al., 2017)
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Requiring a Multisectoral, Integrated, and Coordinated Approach Addressing upstream factors -- individual behaviors, social needs, racism, and the environment -- will promote whole health, but doing so will require collaborations across sectors of care that go well beyond physical, mental, and behavioral health. For example, whole health requires housing,
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Decades of evidence on community health centers (CHCs) , which broadly include a range of practices that care for underserved and vulnerable populations (e.g., free clinics, federally qualified health centers, safety net practices, public health clinics, etc.)
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. Other studies have shown that Medicaid expansion is associated with sustained increases in recommended clinical preventive services among lower-income people (Song and Kucik, 2022)
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, has since evolved to encompass measures of patient satisfaction and well-being and the quality of care rendered to entire populations for which a health care practice (O'Malley et al., 2019a) or system, such as an accountable care organization (Fisher and Shortell, 2010)
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From page 88... ...
Empanelment The concept of empanelment illustrates how a specific form of accountability can facilitate equity within a given population. Empanelment is the process of assigning everyone in a given population to an interprofessional care team or team member that is responsible and accountable for their care.
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From page 89... ...
While it is logical to assume that larger panels are associated with worse patient outcomes, worse patient experiences, and clinician burnout, a recent systematic review on the topic revealed that the evidence substantiating these assumptions is limited (Paige et al., 2020)
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. 4 Most of the research regarding health care team well-being focuses on clinicians and not the broader health care workforce, and within this literature, the vast majority of studies focus on physicians.
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. A systematic review found a relationship between high levels of burnout and reductions in patient safety (Garcia et al., 2019)
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Organization-Level Interventions According to a systematic review and meta-analyses on interventions designed to prevent or reduce physician burnout (Panagioti et al., 2017) , organization-directed interventions are more likely to reduce the incidence of burnout than individual-directed interventions, such as mindfulnessbased stress reduction training.
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From page 93... ...
. A study of 715 small- to medium-sized primary care practices participating in an Agency for Healthcare Research and Quality initiative to implement evidence-based cardiovascular preventive care was intended to identify the characteristics of the 30 percent of practices that reported zero burnout as compared with practices that reported high levels of burnout.
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. FINDINGS AND CONCLUSIONS This chapter summarizes the evidence supporting the committee's five foundational elements of whole health: (1)
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There is evidence that health systems can improve many upstream factors such as health behaviors and mental health, and there is a growing body of evidence that shows that health systems can even improve social determinants, environment, and systemic racism and sexism. To address these complex issues, partnerships and collaboration are needed among health systems, community programs, social services, and public health agencies.
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Cochrane Database of Systematic Reviews 10:CD006525. Armstrong, G
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2017. Integrated care clinic: Creating enhanced clinical pathways for integrated behavioral health care in a family medicine residency clinic serving a low-income, minority population.
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2015. Diagnoses, intervention strategies, and rates of functional improve ment in integrated behavioral health care patients.
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2008. Clos ing the gap in a generation: Health equity through action on the social determinants of health.
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2018. A qualitative study of patient experiences of care in integrated behavioral health and primary care settings: More similar than different.
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Preventive Services Task Force.
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From page 102... ...
2001. Ambulatory care sensitive hospital izations and emergency visits: Experiences of medicaid patients using federally qualified health centers.
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2021. Allostatic load and its impact on health: A systematic review.
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2018. Primary care behavioral health (PCBH)
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From page 105... ...
2001. Improving adolescent preventive care in community health centers.
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Preventive Services Task Force methods considerations for research. American Journal of Preventive Medicine 57(6)
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From page 107... ...
2013. Patient-centered approaches to health care: A systematic review of randomized controlled trials.
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2022. The impact of warm handoffs on patient engagement with behavioral health services in primary care.
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2020. The impact of primary care behavioral health services on patient behaviors: A randomized controlled trial.
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2019. The cost effective ness of embedding a behavioral health clinician into an existing primary care practice to facilitate the integration of care: A prospective, case–control program evaluation.
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Systematic Reviews 10(1)
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The Task Force on Community Preventive Services. American Journal of Preventive Medicine 18(1 Suppl)
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An analysis of handoffs for primary care behavioral health consultation on patient engagement and systems utilization. Clinical Practice in Pediatric Psychology 8(3)
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From page 114... ...
Annals of Family Medicine 19(6)
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